Like so many of my colleagues, I longed for the emergence of an electronic health record (EHR) that had the potential to transform health care delivery. Over the years, I volunteered for committees promoting this effort but became discouraged by the many barriers. Finally, EHRs arrived, along with the creation of health information technology (HIT) companies that produced, profited from and promoted versions that have been widely distributed to hospitals and outpatient clinics. All promised to reduce errors, increase efficiency and restrain health care costs.
Admittedly, I am not tech-savvy. I find little intuitive about web pages, e-devices and e-media and I'm not a fan of the trial-and-error approach to problem solving, especially as it pertains to health care. However, I was excited about the potential benefit an EHR promised, so when a top-of-the-line version arrived at our institution for inpatient care, I was keen to try it. My initial enthusiasm was quickly dampened when it was introduced in the outpatient clinic. The long training sessions showed me multiple ways to do things I did not need for a patient encounter, without focusing on those that I did.
One physician's experience
The day we went live with our EHR was a nightmare. Even my tech-savvy colleagues were dismayed. I heard that another institution using a similar product had 6,000 "notices" of problems on the first day their system was rolled out to multiple hospital and clinic sites. So what went wrong?
As with any system, an EHR produces the outcome for which it was designed. The most widely used EHRs are designed for auditing, compliance and billing. They are not designed for more efficient patient care in the office, better communication among providers, or the collection of group data for quality improvement efforts. As yet, there is no evidence that the use of an EHR provides less expensive care and/or better outcomes.
Medical record templates do not lend themselves to either recording or reporting meaningful clinical information. Details of a patient's story can be lost in a format that boxes individuals into disease categories, making it hard, for example, to distinguish one person with diabetes from another. Judicious use of cut-and-paste can save time and provide continuity with previous encounters. Poor use of it can perpetuate errors, and such files are often so poorly edited that two contiguous sentences can contradict each other.
Rather than being easier to read and navigate, encounter documents are longer, filled with extraneous information, and often lack the key elements of the physician's thoughts behind the assessment and plan. "Where are those informative notes we used to receive following our patient's visit to subspecialty clinic?" asked one of the community physicians who was swamped by the size and redundancy of the office notes he now receives and must file from consultants. Sadly, this problem affects us all.
After several months, I can now negotiate the system, but it still takes more time, effort, concentration and emotional energy than it should. The satisfaction of the examining-room encounter with my patients is compromised more than I could have possibly imagined. Furthermore, our high-priced EHR cannot import laboratory values from other organizations, is not configured to provide us with group data about blood pressure control and cannot electronically send our records to doctors outside our system with whom we share patient care.
EHR design flaws
One serious barrier to removing design flaws and other software hazards is the typical EHR vendor license, which includes a gag clause that prohibits purchasers and users from sharing information about software problems with anyone outside of their organizations. Such restrictions are an anathema to the development of cooperative enterprises that can find solutions that will facilitate not hinder patient care.
EHRs are not without their pluses. Computerized prescriptions, though not error proof, do seem to be safer than handwritten ones. Though restricted to information entered into the e-record, patient care is enhanced by physicians being able display laboratory values showing the progression of a condition or details, including images, of a disorder that needs addressing. But this is not enough.
Take control of the process
As physicians and physician organizations, we must take control of the electronic medical record. If ever there was an issue that should unite not just internal medicine but all specialties, it is this. The medical record exists first and foremost for the patient and providers to maintain historical information and allow communication among health care team members. Patients are entitled to have health records that are accurate, reflect their problems and are in a format that enables all their doctors to communicate effectively with each other.
We need to insist that anything our institutions purchase for physician use fulfills the criteria for better patient outcomes, patient experience and meaningful use, and that its programmers can transform critical feedback into a better product.
We need programmers to expand on the strengths of EHRs and to make new and existing systems more user-friendly, efficient, and easily accessible when we seek information for quality measures. Patient safety should govern vendor contracts, not intellectual property ownership, liability or gag clauses.
EHRs should be designed so physicians do fewer clerical tasks and more patient-related ones. Physician time is valuable for patients who want to talk with us, hear our explanations and advice and feel assured that someone has an interest in both their disease and their well-being.
ACP is a founding partner of AmericanEHR Partners, an online community designed to provide all health care professionals with credible information about many different EHRs and a comparison tool to review ratings and features. Eleven medical societies and two more practice management societies provide content. There are now 10,000 registered users and more than 2,500 surveys. There is also information about subjects such as meaningful use and Medicare and Medicaid incentive programs. College staff, Fellows and Masters represent practicing clinicians on the government HIT policy and standards committees and organizations whose purpose is to ensure that new systems are usable, interoperable, safe and effective.
As physicians we have a responsibility to work with others to ensure that EHRs are designed and used to improve patient and physician satisfaction, increase productivity and promote high-value, cost-conscious care. Join me and the College in our efforts to enable this exciting technology to realize its as yet unfulfilled promise.